SLR - June 2022 - Victor J. Putz, DPMReference: Ghaddaf AA, Alomari MS, Alsharef JF, Alakkas E, Alshehri MS. Early versus late weightbearing in conservative management of acute achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. Injury. 2022. Apr;53(4):1543-1551.
Level of Evidence: I
Scientific Literature Review
Reviewed By: Victor J. Putz, DPM
Residency Program: McLaren Oakland Hospital (Pontiac, MI)
Podiatric Relevance: Achilles tendon ruptures (ATR) are among the most frequently seen tendon injuries in the podiatric patient population. While the condition can be managed surgically, the interest in conservative management has been increasing, considering it produces comparable functional outcomes with fewer complications. Conservatively immobilizing the Achilles tendon through cast application and non-weightbearing (NWB) has been commonly utilized to provide protection during healing despite its effects on muscle atrophy and joint stiffness. The goal of this study was to assess the impact of early versus late weightbearing (WB) on clinical outcomes of adults with conservatively treated ATR.
Methods: A systematic review was performed across eight randomized controlled trials comparing early and late WB with ATR. The population of this study included 1086 patients with 50.37 percent randomized to the early WB group and 49.63 percent to the late WB group. Acute injuries were defined as occurring in less than 14 days and early WB was defined as within four weeks of treatment. The measured and compared outcomes included the following: re-rupture rate, Achilles tendon rupture score (ATRS), return to pre-injury sport activity, time to return to work, and adverse events. Meta-analysis was conducted utilizing risk ratio and standardized mean differences. Risk ratio was used to represent the outcomes of rerupture rate, return to sports, and adverse events. Standardized mean differences were used for the continuous outcomes of ATRS and time to return to work. A subgroup analysis was performed for the ATRS follow-up periods.
Results: The outcomes of both early and late WB groups were found to be similar with no significant differences for re-rupture rate, ATRS, return to pre-injury sport activity, time to return to work, and adverse events. The subgroup analysis of the ATRS intervals of 3-, 6-, 9-, and 12-months also showed similar findings. The authors claim that this is the largest systematic review to date which compares early and late WB for conservative management of acute ATR. They also emphasize that this review assessed the ATRS score, which had not been done in previous systematic reviews, provides thorough analysis on the strength and functionality of the healed tendon.
Conclusions: When conservatively treating patients with ATR, early WB should be strongly considered with the benefits of being a safe, cost-effective, and shorter treatment option. Early rehabilitative protocol may even include the use of a removable ankle brace which would allow earlier ankle mobilization and gradual WB. The early WB strategy can minimize the pathological effects of immobilization in addition to eliminating the unnecessary inconveniences on patient’s activities of daily living with longer intervals of casting and NWB. No consideration was given to the size of thea ATR defect, which could be the focus of futures studies and provide greater clinical relevance.